Citation Nr: 9920409
Decision Date: 07/23/99 Archive Date: 07/28/99
DOCKET NO. 94-16 961 ) DATE
)
)
On appeal from the
Department of Veterans Affairs Regional Office in Houston,
Texas
THE ISSUES
1. Entitlement to service connection for a psychiatric
disorder as secondary to a head injury.
2. Entitlement to service connection for a seizure disorder
as secondary to a head injury.
REPRESENTATION
Appellant represented by: Disabled American Veterans
WITNESS AT HEARING ON APPEAL
Appellant
ATTORNEY FOR THE BOARD
Stephen L. Higgs, Associate Counsel
INTRODUCTION
The veteran served on active duty from August 1966 to
September 1969.
This matter comes to the Board of Veterans' Appeals (Board)
on appeal from a rating decision dated in May 1991 by the
Department of Veterans Affairs (VA) Regional Office (RO) in
San Diego, California.
FINDINGS OF FACT
1. All relevant evidence necessary for an equitable
disposition of the veteran's appeal has been obtained by the
RO.
2. Other than a laceration over the occiput, the veteran did
not receive a head injury which elicited medical observation
and treatment as a result of his February 1967 motor vehicle
accident.
3. The veteran's claimed seizure disorder has not been
confirmed by medical observation.
4. It is more likely than not that if the veteran does have
a seizure disorder, it is not the result of an inservice head
injury.
5. It is more likely than not that the veteran's psychiatric
problems are not the result of an inservice head injury.
CONCLUSIONS OF LAW
1. A psychiatric disorder was not incurred in or aggravated
by active service. 38 U.S.C.A. §§ 1110, 5107(a) (West 1991);
38 C.F.R. §§ 3.303, 3.304 (1998).
2. A seizure disorder was not incurred in or aggravated by
active service. 38 U.S.C.A. §§ 1110, 5107(a) (West 1991);
38 C.F.R. §§ 3.303, 3.304 (1998).
REASONS AND BASES FOR FINDINGS AND CONCLUSIONS
Factual Background
Service medical records dated in February 1967 reveal that
the veteran was admitted to the hospital after being struck
by an automobile while walking along the road. The
admission diagnosis was scrotal hematoma. A gross
neurological examination was normal. Subsequent service
medical records describe injuries to the right groin and
pelvic area.
A Medical Board Report dated in May 1967 states that the
veteran did not lose consciousness after the accident but had
multiple small abrasions of the right shoulder and forearm,
and pelvic injuries. The diagnoses indicated were diastasis,
symphysis pubis; left sacro-iliac joint separation; and
laceration over occiput.
The diagnoses upon inservice examination in January 1968 was
diastasis of symphysis pubis, and left sacroiliac joint
separation. The diagnoses reflected in treatment and
examination records in September 1968 was diastasis of
symphysis pubis, and left sacroiliac joint separation. The
separation physical examination was silent for a seizure
disorder or psychiatric problems.
In November 1969, the veteran underwent a VA neuropsychiatric
examination. The medical history included details of the
February 1967 automobile accident. By history, the veteran
related that he was knocked unconscious and could not
remember facts other than those stated at the time, and that
he was unconscious less than 24 hours, and was hospitalized.
He served out his period of duty and received an honorable
discharge. With this background he was seen by the VA
examiner. The VA examiner reported that from a neurological
standpoint the veteran was completely normal in all respects.
A November 1973 VA Special Report of Training states that the
veteran was having an extreme mental problem which tended to
jeopardize his training at the University. The veteran had
been sent to a doctor for treatment, who confirmed that the
veteran was indeed in an acute schizophrenic break. The
veteran was prescribed medication, which was apparently
helpful.
During a VA examination in December 1974, the veteran was
found to have no significant personality or psychiatric
abnormalities.
Multiple medical records dated in 1978, 1979, and 1980
include diagnoses of schizophrenia and chronic paranoid
schizophrenia. One of the earlier medical histories given by
the veteran, in an October to December 1978 report of
hospitalization, indicates that he reported that he had been
experiencing increasing amounts of deja-vu, thought
communication, spiritual communication, visions of
cosmological significance and other paranormal phenomena
since June 1978. The onset was described as sudden, when the
veteran began to experience visions while sitting at a local
bar one evening. The diagnosis was schizophrenoform
psychosis.
VA records of treatment and hospitalization dated from 1989
to 1991 reflect problems with multiple substance abuse,
intermittent alcohol abuse, and psychosis to include visual
and auditory hallucinations.
The veteran was hospitalized at a VA facility from January
1991 to February 1991. The hospitalization summary reflects a
diagnosis of psychosis, not otherwise specified, versus
schizophrenia. The hospitalization summary details the
veteran's psychiatric history, including a first episode of
auditory and visual hallucinations in 1972, "at which time
he was using speed, pot, alcohol and LSD." His first
hospitalization was at Letterman Army Hospital in San
Francisco in 1978, for about a year. The most recent
hospitalization had been in Phoenix in 1989.
In March 1991 he presented at a VA medical center with status
post substance abuse (sleeping pill overdose) and sought a
cure for his visions and hallucinations.
In April 1991 the veteran initiated his claim for service
connection for residuals of the claimed inservice head
injury. In the statement, he indicated that he was in an
auto accident in January of 1967, during which he received
head trauma which rendered him unconscious for 3 to 4 days.
He asserted that during the accident he hit his head on a
steel railing as he flipped over the car.
An August 1993 VA medical certificate approved refill of the
veteran's medications, based on a "known seizure disorder."
During his October 1994 RO hearing, the veteran testified
that after his inservice automobile accident he was initially
hospitalized for 4 months. He said he vaguely remembered
waking up in the hospital 2 or 3 days after the accident. He
said he was told he had a laceration over his occiput. He
described problems with mood swings, depression and confusion
after the accident, affecting his inservice performance. He
said he was first diagnosed with a seizure-type disorder at a
VA hospital in 1990. He said he was told in 1978 that he had
mesial temporal sclerosis which was overshadowed by
psychological problems. He asserted that he was still
experiencing residuals of the inservice head trauma, and
described his ongoing problems with seizures and psychiatric
disturbances.
A treatment record dated in September 1994 reflects that the
veteran was receiving medication for seizures. The
medication was increased because although the last seizure
was in August 1993, he was having auras, confusion and
forgetfulness. The conditions for which the veteran sought
treatment included a seizure disorder, and organic brain
syndrome status post head injury.
A February 1995 report of a computerized axial tomography
included a clinical history of grand mal epilepsy with
partial seizures, post traumatic. The examiner's impression
was mild to moderate cortical atrophy for a patient of the
veteran's age group. No prior CT head studies or MRI studies
were available for comparison.
A February 1995 EEG report includes an impression of abnormal
EEG, showing a slightly disorganized background which was
probably on the basis of a medication effect. There also was
a sharply contoured left frontotemporal theta activity,
strongly suggestive of a focal disturbance of cerebral
activity in that region with possible epileptiform activity.
The examiner stated that this finding could be seen as a
result of head injury, and could be seen as an interictal
pattern, and was most consistent with the interictal
expression of complex partial seizure disorder.
The referring portion of a February 1995 VA medical
consultation sheet describes the veteran as having a seizure
disorder, consistent with an abnormal EEG interpreted by
another physician. The veteran was also noted to have audio-
visual hallucinations which were well organized and
recurrent. The veteran stated he had been told that his
audio-visual hallucinations were strictly related to his
seizure disorder and not of psychiatric etiology. The
referring physician noted that old records obtained suggested
otherwise. A second referring portion of a consultation
sheet dated in February 1995 describes as the reason for
request, "grand mal episodes with partial seizures (post-
traumatic)."
An undated medical record, apparently prepared in the March
to April 1995 time frame, includes a diagnosis of "seizure
d/o 1960's, ? MVA."
An August 1995 VA record of treatment includes a diagnosis of
seizures, with no elaboration.
During a December 1997 VA neurological examination, the
veteran was diagnosed with status post closed head injury,
1967; and a generalized seizure disorder, completely
controlled on anticonvulsants. According to the report, the
examiner did not have the claims file available, and history
was obtained only from the veteran. The examiner noted that
the veteran began having generalized seizures in the early
1990's. The examiner opined that the etiology was either
idiopathic or secondary to his service-connected head injury;
and that the veteran's prior evaluations when he first began
having his generalized seizures suggested that there was
evidence to indicate that they were secondary to the head
injury. The examiner noted that the relatively long length
of time in between the veteran's head injury and his
subsequent generalized seizures raised some question as to
whether his head injury was causative. However, the examiner
opined, there was apparently no other etiology for his
seizure disorder. Immediately following his injuries he
began having complaints consistent with psychotic features
with agitation and confusion. The examiner opined that at
this point in time it would be difficult to absolutely
exclude superimposed complex partial seizure disorder.
However, the examiner further commented, in the absence of
documentation of such episodes as being a seizure or
epileptiform activity on an EEG, it was most likely that his
symptoms were all related at that time to his psychiatric
disorder. The examiner indicated that he would obtain an EEG
in order to look for evidence of an interictal spike or other
focal abnormality that would at least be consistent with
seizure disorder resulting from prior head injury.
Three days later, after having had an opportunity to
thoroughly review the claims file, the neurological examiner
prepared an addendum to the report. He also had taken the
opportunity to speak with a VA psychiatrist who also had
examined the veteran. The examiner revised his impression to
status post closed head injury, 1967, and no clear evidence
of active seizure disorder. He found no documentation of
residual neurologic deficit upon discharge from service in
1969. He opined that if the veteran had an organic brain
syndrome or organic psychosis as a result of his head injury,
his symptoms would have been maximal around the time of his
head injury rather than having progressed in subsequent years
as occurred in the veteran. He concluded that the veteran
did not have a post traumatic seizure disorder.
The veteran also underwent a separate VA psychiatric
examination in December 1997. The examiner indicated that
information was obtained from the veteran and from extensive
review of the claims file. He prepared a 5-page detailed
history of the veteran's head trauma and subsequent claimed
seizure disorder and psychiatric complaints and treatment, as
ascertained from study of the claims file and history as
obtained by the veteran. Upon mental status examination, the
veteran was cooperative with the examiner. No abnormalities
of motor activity were noted initially. However, when the
veteran was asked to write, and copy a design during the
mental status examination, he was noted to be extremely
tremulous. His handwriting was almost illegible, and
although he was able to copy a design correctly, his lines
were not straight. He made good eye contact with the
examiner. His speech was fluent in a normal rate and rhythm,
without any particular accent, and he had a sophisticated use
of language. His predominant affect was euthymic and broad,
and appropriate to his expressed thought without any lability
noted. The veteran's thought processes were coherent. At
the time of the interview, he appeared to be without
preoccupations, obsessions, delusions or hallucinations. At
the time of the interview, he was completely without specific
ideas, intentions, or plans of harming himself or others, and
his associations were tight. He scored 27/30 on the
Folestein Minimental Status Exam. He was awake, alert and
oriented. He performed serial three subtractions correctly
and serial seven subtractions correctly; however, he was
able to repeat three words immediately, but could not
remember them after five minutes. His fund of information
was intact. His insight and judgment were fair.
The diagnosis was psychotic disorder, not otherwise
specified. The examiner commented that the veteran gave a
history of having intermittently functioned extremely well,
and at other times extremely poorly. He noted that the
veteran reported that he had a seizure disorder; but that
nowhere in that chart up to this point in time had this ever
been confirmed. It was the examiner's opinion that if the
veteran had a presentation that was consistent with an
organic mental disorder, then it would be possible for this
disorder to be related to the accident that he had in 1967;
however, in the examiner's view, the veteran did not report a
history which was consistent with a psychiatric disorder
following a closed head injury. According to the examiner,
in such cases the symptoms are worse immediately afterwards
and have gradual improvement, which did not seem to be the
case with the veteran. The veteran indicated that he had
some psychiatric symptoms, but they became worse with time,
not better.
In the examiner's opinion, it was unlikely that the veteran's
psychiatric problems were a result of the head injury that he
sustained in the service in February of 1967. It was not
clear to the examiner that the veteran had a seizure
disorder. The examiner asserted that the mere fact that his
symptoms improved with Tegretol did not prove that he had a
seizure disorder. The veteran had experienced multiple
episodes of hospitalization without any seizure activity
being witnessed by anyone, and although the possibility
always remained that the alleged head injury in 1967 was
causative, the examiner opined that it was with a probability
of considerably less than 50 percent.
The veteran underwent a VA examination by a VA psychologist
in January 1998. According to the examination report, the
examination included a review of the veteran's chart, a
clinical interview, and several psychological tests. The
examiner summarized his findings by stating that the result
of neuropsychological evaluation revealed inconsistent
results. However, qualitative review of the veteran's
responses did not give the suggestion of closed head injury.
Results of this examination were diametrically opposite from
results of previous examinations where the veteran was
allegedly using odd language that was diagnosed as aphasic
disorder. Moreover, he had been inconsistent on results of
I.Q. tests, sometimes scoring in the superior range,
sometimes in the average, and now within the borderline
range.
The examiner opined that the examination did not reflect the
type of results typically seen with a closed head injury
where the veteran may have minimal learning, though he had
better recognition recall. The veteran was unable to
recognize any of the words on the list as having been
presented, and this was a very unusual finding. The MMPI
indicated the presence of a thought disorder. It was clear
from the long psychiatric history that these difficulties had
been pervasive and were not typical of residual emotional
problems, such as depression and anxiety following a head
injury. Rather, the veteran exhibited disorganized thinking
that was more consistent with a diagnosis of psychotic
disorder. The examiner did not feel that the disorder was
secondary to the inservice head injury, as this was not the
typical pattern seen with head-injured individuals.
According to the examiner, the veteran displayed more of an
idiopathic psychotic disorder.
A January 1998 VA MRI of the brain revealed minimal expansion
of the left temporal horn of the lateral ventricle. The MRI
report states that this could be a normal variant or could
reflect focal left temporal lobe atrophy, although no
definite temporal lobe sclerosis could be seen. The report
recommends that one should correlate this with the history
and EEG findings to help determine if there is also a
clinical left temporal lobe seizure focus. Even if this is
the focus, the report elaborates, it is not a tumor, but
rather is a focal scar from prior insult. No other lesions
were seen.
Analysis
Service connection may be established for a disability
resulting from personal injury suffered or disease contracted
in the line of duty or for aggravation of a preexisting
injury suffered or disease contracted in the line of duty. 38
U.S.C.A. § 1110 (West 1991). Regulations also provide that
service connection may be granted for any disease diagnosed
after discharge, when all the evidence, including that
pertinent to service, establishes that the disease was
incurred in service. 38 C.F.R. § 3.303(d).
A disorder may be service connected if the evidence of
record, regardless of its date, shows that the veteran had a
chronic disorder in service or during an applicable
presumptive period, and that the veteran still has such a
disorder. 38 C.F.R. § 3.303(b); Savage v. Gober, 10 Vet.
App. 488 (1997). Such evidence must be medical unless it
relates to a disorder that may be competently demonstrated by
lay observation. Savage. If the disorder is not chronic, it
may still be service connected if the disorder is observed in
service or an applicable presumptive period, continuity of
symptomatology is demonstrated thereafter, and competent
evidence relates the present disorder to that symptomatology.
Id.
Secondary service connection shall be awarded when a
disability "is proximately due to or the result of a service-
connected disease or injury". 38 C.F.R. § 3.310(a) (1998).
Additional disability resulting from the aggravation of a
non-service-connected condition by a service-connected
condition is also compensable under 38 C.F.R. § 3.310(a).
Libertine v. Brown, 9 Vet. App. 521, 522 (1996); see also
Reiber v. Brown, 7 Vet. App. 513, 515-16 (1995); Allen v.
Brown, 7 Vet. App. 439, 448 (1995) (en banc). A claim for
secondary service connection must be well grounded, 38 U.S.C.
§ 5107(a); see Proscelle v. Derwinski, 2 Vet. App. 629, 633
(1992), and thus, supported by medical nexus evidence, see
Velez v. West, 11 Vet. App. 148, 158 (1998); Caluza, supra.
The Board finds that the veteran's claims for service
connection for a seizure disorder and for a psychiatric
disability are "well-grounded" within the meaning of 38
U.S.C.A. § 5107(a). The veteran has presented a claim which
is not inherently implausible, with medical evidence linking
the claimed current disabilities to an inservice head injury,
and the Board is satisfied that all relevant facts have been
sufficiently developed.
The medical opinions which tend to relate the veteran's
current psychiatric and purported seizure disorders to an
inservice head injury appear to be based on a very flawed
history presented by the veteran and repeated, without
verification, by some of the examiners. The Board can find
no evidence in the original inservice treatment records that
the veteran actually received the claimed head injury (other
than a laceration to the occiput) or that he was rendered
unconscious as a result of the February 1967 accident. The
veteran's April 1991 claim that he was rendered unconscious
for 3 to 4 days after the inservice accident appears to be
incorrect. The November 1969 VA neuropsychiatric examination
reflects a history of the veteran having been knocked
unconscious less than 24 hours after the February 1967
accident, but even this history is rendered dubious by the
service medical records. In assessing the accuracy of these
histories, the Board is acutely mindful that, as noted above,
the Medical Board Report dated in May 1967 states that the
veteran did not lose consciousness after the accident but had
multiple small abrasions of the right shoulder and forearm,
and pelvic injuries. The diagnoses indicated were diastasis,
symphysis pubis; left sacro-iliac joint separation; and
laceration over occiput. The Board is also mindful that in
November 1969 a VA examiner found the veteran to be
completely normal in all respects from a neurological
standpoint. This is consistent with the January 1998 VA
examining psychologist's opinion that qualitative review of
the veteran's responses during examination did not give the
suggestion of a closed head injury and that the veteran's
psychotic disorder was not secondary to the inservice head
injury. Similarly, the December 1997 VA psychiatric
examiner assert that the veteran had experienced multiple
episodes of hospitalization without any seizure activity
being witnessed by anyone, and that although the possibility
always remained that the alleged head injury in 1967 was
causative, it was with a probability of considerably less
than 50 percent.
The above opinions are not inconsistent with the January 1998
VA MRI report, in which the veteran's condition evaluated as
possibly being a "normal variant."
In December 1997, the VA neurological examiner found that the
veteran's seizure disorder could be related to his inservice
head injury; but after reviewing the record three days
later, he stated there was no clear evidence of a seizure
disorder, and effectively ruled out organic brain syndrome
due to the inservice automobile accident. This change in
diagnosis underscores the importance of whether an accurate
medical history was available in weighing the medical
opinions of record.
In any event, the round of December 1997 to January 1998 VA
neurological, psychiatric, and psychological examinations
reflect that after a thorough review of the claims file and
an accurate understanding of the medical evidence and medical
history of record, the medical professionals conducting these
examinations agreed that it was unlikely that the veteran's
psychiatric problems were related to an inservice head
injury. This was in significant part based on lack of
evidence of a commensurate head trauma, and the observation
that the symptoms had become worse, not better (as one would
expect post head trauma), during the years after the initial
claimed trauma.
As for his seizure disorder, these examiners created
substantial doubts as to whether the veteran had a seizure
disorder at all. Two examiners indicated that no seizure had
ever been observed during the substantial periods of time
while the veteran was under medical observation or treatment.
In any event, after reviewing the record in full, the
neurological examiner's view was that it was unlikely that
the veteran had a seizure disorder which was related to the
claimed inservice head trauma.
In sum, based on the medical evidence of record, the Board
finds that it is more likely than not that the veteran did
not experience a head trauma (other than a laceration to the
occiput) which elicited medical treatment during the February
1967 automobile accident; that it is more likely than not
that the veteran's psychiatric problems are not due to an
inservice head trauma; that is more likely than not that the
veteran does not have a seizure disorder; and that it is
more likely than not that if the veteran does have a seizure
disorder, it is not related to an inservice head trauma.
Since the preponderance of the evidence weighs heavily
against the veteran's claims for service connection for
psychiatric and seizure disorders as secondary to an
inservice head trauma, these two claims are denied.
ORDER
Service connection for a psychiatric disorder is denied.
Service connection for a seizure disorder is denied.
RENÉE M. PELLETIER
Member, Board of Veterans' Appeals